1A CASE SCENARIO ASSIGNMENTNameInstitutionProfessorCourseDate
2Patient StatusHistory of presenting illnessThe patient was brought in our facility with problem of shortness of breath, worsening fastbreathing, and failure of performing activities of daily living due to the condition. The situationof the patient is becoming worse when patient is performing simple task such as activities ofdaily living and sometimes when sleeping. The condition seems to be worsening according to thepatient description whereby A.R cannot tolerate the dyspnea. The condition started to worsen in aweek ago where some of the tests like respiratory function test which turned positive. The historyof presenting illness based on the studies, help in achieving a differential diagnosis that will inthe treatment modality of the patient. it is a vital tool that is used in the clinical setting to crackthe patient according to signs and symptoms from the chief complains(Mazer et al., 2016).Past medical historyA.R has medical history of admissions in various health facilities which offered treatment to thefollowing diagnosis. The first diagnosis to be done was arthritis followed by Asthma, breastcarcinoma, hypertension, and stroke problem which was managed well in inpatient facility.These are the major diseases that affect the individual life by compromising the body function.Studies show that at some point, any chronic disease of any major organ starts to affect otherorgans and make them fail to function properly. At this point, we can argue that the issue withrecent test running positive to prove a respiratory failure might be associated with theseconditions.The patient is known to have allergies of codeine which makes the client to react by severeitching until managed appropriately. The patient has neither history of substance use nor history
3of smoking or alcohol taking. The patient might have been using codeine for pain treatmentbecause in the past medical history, A.R has been diagnosed with breast cancer. According totreatment ladder of pain in cancer, codeine is the best option that can be used to manage painassociated with cancer prognosis.Past Surgical historyThe patient has a previous history of brain surgery which was done some years back. There wereno noted complications after surgery and reversed to normal self. A.R has no history of bloodtransfusion and no other major surgery performed. Based on the history, there is no data to showus why A.R was scheduled for a brain surgery in the previous medical history.Family historyThe purpose of family history is to help identify the associated factors to the patient conditionsuch as history of cancer and any other chronic disease in the family. The other reason is toidentify the risk factor of the patient developing the same disease. Studies show that theseconditions have a hereditary factor that runs through the family.
Upload your study docs or become a
Course Hero member to access this document
Upload your study docs or become a
Course Hero member to access this document
End of preview. Want to read all 17 pages?
Upload your study docs or become a
Course Hero member to access this document
Term
Spring
Professor
Mr. Kinyanjui
Tags
